Korean Circ J.  2016 Jul;46(4):433-442. 10.4070/kcj.2016.46.4.433.

Women and Ischemic Heart Disease: Recognition, Diagnosis and Management

• Park SM
• Merz CN

• KMID: 2344417
• DOI: http://doi.org/10.4070/kcj.2016.46.4.433

Abstract

Cardiovascular disease is one of the most frequent causes of death in both males and females throughout the world. However, women exhibit a greater symptom burden, more functional disability, and a higher prevalence of nonobstructive coronary artery disease (CAD) compared to men when evaluated for signs and symptoms of myocardial ischemia. This paradoxical sex difference appears to be linked to a sex-specific pathophysiology of myocardial ischemia including coronary microvascular dysfunction, a component of the 'Yentl Syndrome'. Accordingly, the term ischemic heart disease (IHD) is more appropriate for a discussion specific to women rather than CAD or coronary heart disease. Following the National Heart, Lung, and Blood Institute Heart Truth/American Heart Association, Women's Ischemia Syndrome Evaluation and guideline campaigns, the cardiovascular mortality in women has been decreased, although significant gender gaps in clinical outcomes still exist. Women less likely undergo testing, yet guidelines indicate that symptomatic women at intermediate to high IHD risk should have further test (e.g. exercise treadmill test or stress imaging) for myocardial ischemia and prognosis. Further, women have suboptimal use of evidence-based guideline therapies compared with men with and without obstructive CAD. Anti-anginal and anti-atherosclerotic strategies are effective for symptom and ischemia management in women with evidence of ischemia and nonobstructive CAD, although more female-specific study is needed. IHD guidelines are not "cardiac catheterization" based but related to evidence of "myocardial ischemia and angina". A simplified approach to IHD management with ABCs (aspirin, angiotensin-converting enzyme inhibitors/angiotensin-renin blockers, beta blockers, cholesterol management and statin) should be used and can help to increases adherence to guidelines.

Keyword

Women; Coronary artery disease; Myocardial ischemia; Microvascular angina; Guideline

MeSH Terms

Cardiovascular Diseases
Cause of Death
Cholesterol
Coronary Artery Disease
Coronary Disease
Diagnosis*
Exercise Test
Female
Heart
Humans
Ischemia
Male
Microvascular Angina
Mortality
Myocardial Ischemia*
National Heart, Lung, and Blood Institute (U.S.)
Prevalence
Prognosis
Sex Characteristics
Cholesterol

Figure

• 

  Fig. 1 Cardiovascular disease mortality trends for males and females in United States from the years 1979 to 1997. This demonstrates increasing mortality for females as a new female majority in contrast to decreased mortality in men. This alarming fact of gender gap was recognized in 1991 as the 'Yentl Syndrome' that when a woman has been shown to have obstructive coronary artery disease, like men, only then she gets the appropriate treatment. Then National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study was commissioned and American Heart Association (AHA) began to take an action.

• 

  Fig. 2 Diagnostic evaluation algorithm for women presenting with suspected ischemic heart disease (IHD) symptoms and intermediate IHD risk and intermediate-high IHD risk. ETT: exercise treadmill testing, ADL: activities of daily living, DASI: Duke Activity Status Index, CCTA: coronary computed tomography angiography, ECG: electrocardiography, SIHD: stable ischemic heart disease, angio: angiography. Reprinted from Mieres et al.35) with permission. Copyright © 2014, American Heart Association, Inc.

• 

  Fig. 3 Relative hazard for all-cause mortality from CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) in younger (aged<65 years) and older (aged≥65 years) women (n=12128) and men (n=11726). Women were at higher prognostic risk for coronary artery disease burden. 1VD indicates 1-vessel disease; 2VD, 2-vessel disease; and 3VD, 3-vessel disease. Reprinted from Mieres et al.35) with permission. Copyright © 2014, American Heart Association, Inc.

• 

  Fig. 4 Cardiovascular disease mortality trends for males and females in United States from the years 1979 to 2004. After National Heart, Lung, and Blood Institute (NHLBI) Heart Truth/American Heart Association (AHA) awareness, Women's Ischemia Syndrome Evaluation (WISE) sex-specific ischemic heart disease research, and American College of Cardiology/AHA guideline campaigns, the US cardiovascular mortality in women has decreased by 43%.

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